<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602152
Report Date: 08/07/2024
Date Signed: 08/08/2024 04:02:00 PM

Document Has Been Signed on 08/08/2024 04:02 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:SANTA FE HOME CARE IIFACILITY NUMBER:
198602152
ADMINISTRATOR/
DIRECTOR:		ASIS, VIRGINIAFACILITY TYPE:
740
ADDRESS:2255 SANTA FE AVENUETELEPHONE:
(424) 558-8285
CITY:TORRANCESTATE: CAZIP CODE:
90501
CAPACITY: 6CENSUS: 2DATE:
08/07/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:40 AM
MET WITH:Virginia AsisTIME VISIT/
INSPECTION COMPLETED:
05:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 08/07/24, Licensing Program Analyst (LPA) Regina Cloyd conducted an unannounced required – annual inspection and met with Caregiver Mignon Diaz. The Administrator Virginia Asis arrived later.

The facility is licensed to serve residents aged 60 and over, six non-ambulatory. They have an approved Hospice Waiver for six residents. Annual Fees are current. The facility is a single-story structure located in a residential neighborhood. It consists of the following: three (3) bedrooms, 2 bathrooms, living room, kitchen, dining room, family room, garage, and a shaded area.



The Caregiver and Administrator accompanied LPA inside and outside the facility during this inspection.

Two (2) resident records were reviewed and, 2 out of 2 resident records had medical assessments. Two residents’ medication was reviewed.

Four (4) staff records were reviewed.

Deficiencies were observed. Due to insufficient time, an annual continuation is required.

An exit interview was conducted and a copy of this report was discussed with Administrator Virginia Asis and left with Caregiver Mignon Diaz.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE: DATE: 08/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/07/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 08/08/2024 04:02 PM - It Cannot Be Edited


Created By: Regina Cloyd On 08/07/2024 at 04:32 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: SANTA FE HOME CARE II
FACILITY NUMBER: 198602152

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)(12)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (12) Hazardous health conditions documents as specified in Section 87411, Personnel Requirements - General.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review the licensee did not comply with the section cited above for one staff member which poses a potential health risk to persons in care. On 08/07/24, LPA Cloyd did not observe a health screening report (LIC 503) with TB results for Staff #5.
POC Due Date: 08/27/2024
Plan of Correction
1
2
3
4
The Licensee will email R5's health screening report with TB results to regina.cloyd@dss.ca by the POC due date. The Licensee will create a licensing document checklist for staff's folders and email it with the facility's Personnel Report (LIC500) by the POC due date.
Type B
Section Cited
CCR
87628(b)
Diabetes
(b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview and record review, the licensee did not comply with the section cited above for one out of two residents which poses a potential health and safety or personal rights risk. On 08/07/24, LPA Cloyd did not observe a restricted health care plan for Resident #1 (R1) injections. LPA saw needles during medication review. Both Home Health Nurse and Staff stated that they assist with injections.
POC Due Date: 08/27/2024
Plan of Correction
1
2
3
4
The Licensee will complete and maintain a current, written record of care for each resident that includes, but is not limited to, the following information listed in 87628(b)(1) - 87628(b)(3). The Licensee will email the information to regina.cloyd@dss.ca.gov by the POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Ulysses Coronel
LICENSING EVALUATOR NAME:Regina Cloyd
LICENSING EVALUATOR SIGNATURE:
DATE: 08/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/07/2024


LIC809 (FAS) - (06/04)
Page: 2 of 2